I need to get up-to-speed on health plan price transparency in coverage, which went into effect on July 1st, 2022. What should I read?
Here are key resources:
- CMS overview
- Beckers announcement
- UT Dallas: The Impact of Healthcare Price Transparency
- Forbes' summary of the situation
- CMS resource page which includes links to the all-important Transparency in Coverage FAQs and other important resources. Point your developers/analysts to this URL for the nitty-gritty of how MRF files are structured and their data definitions
What are the penalties for failing to comply with the CMS mandate?
Plans (as well as self-insured employers) not in compliance could face fines of up to $100 per day for each violation and for each individual affected by the violation. See Healthcaredive News
As of early December 2022, CMS has not announced any files, even though numerous payers have failed to publish in a timely fashion, or have published obviously flawed files, or have made it unreasonably difficult to find or download their data. CMS waited for more than 6 months before announcing fines to hospitals for failure to properly publish hospital price transparency data, so there is precedent in giving payer organizations (and self-insured employers and their TPAs) private warnings before imposing fines.
How do I find health plan price transparency files?
Transparency files are supposed to be no more than about "two hops" from a consumer-friendly home page for a health plan or self-employed insurer or their TPA, but this is rarely the case. Expect to comb through a network/carrier's web site. There are no definitive web sites with links, but a few lists have been shared:
- Google Doc Spreadsheets
- AMWINS Connect Carrier Availability of MRF
The CMS guidance on finding the MRFs is reproduced below:
The Transparency in Coverage final rules require plans and issuers to make available the machine- readable files on their websites, but the Departments play no active role in publishing the files. If you're not able to easily find a plan's machine-readable file on the plan's website, we recommend that you use an internet-based search engine and search for key words associated with the required disclosures, including (but not limited to) "machine readable files," "transparency in coverage," "in- network rates," and "out-of-network allowed amounts," along with the plan's or issuer's name. If you are still unable to find a plan's or issuer's machine-readable files, please consider contacting the plan or issuer directly to ask them about the location of the required disclosures. If the plan or issuer is unable to direct you to the location of the required disclosures, you may inform CMS of these circumstances by navigating to the Contact Us page and submitting a complaint.
Source is "Where can I find the machine-readable files?" at CMS
Where are the best forums for asking questions about the CMS mandate?
Subscribe to the discussion group, so fresh messages are emailed to you automatically.
Note that the CMS has an email inbox for taking complaints, but this GitHub discussion group, maintained by a CMS paid contractor, is the sole source for help from CMS.
I understand there is a CMS Validation tool. Tell me about it.
A summary description is provided at CMS Resources question #30:
Answer #30: CMS developed a downloadable schema validator tool that plans and developers can use to assess whether their machine-readable files are compliant with the Transparency in Coverage JSON schema. The validator tool and instructions can be accessed here. The tool can be used to validate In-Network rate and Allowed Amount files, as well as provider references and table of contents files. Note that the tool tests for attributes required under version 1.0 of the JSON schema and for syntax errors, but does not test the accuracy of the data in the schema. It is designed to run on local computers and can be used to validate files of any size (there is no file size limit). At this time, the validator tool can only be used to validate JSON files.
Here are important details:
- The validator is primarily useful for the organization that produces the as a baseline check on whether the MRF was produced properly
- Use of the CMS Validator alone may be insufficient for payers/self-insured employers to attest to satisfying the CMS transparency mandate; we look for further guidance from CMS. The source code (not a ready-to-run program) is provided by CMS on github for free
- Strong developer skills are required to build the program from the GitHub source code repository
- A github discussion group with Q&A
- To use the validation tool, you must locate the MRF, download it to your computer or VM and then run it
- Does detect flawed JSON structure, and for valid syntax (e.g. proper hierarchy of elements)
- Doesn't catch misnamed fields or missing 'optional' fields that may make an MRF unusable, nor accuracy of the data
- Diagnostics are minimal
As a self-insured employer what is my interest in transparency MRF?
Here are a few reasons that self-insured employers must pay attention to the MRF mandate:
- Each year the self-insured plans must file an attestation that they have abided by the MRF mandate, along with their TPA. We lack details on this, but clearly the potential for non-compliance fines does exist.
- It's a good business practice to compare rates given to other organizations in your same geographical area, especially during a high inflationary period.
- Protect your employees from excessive out-of-pocket expenses by inspecting prices for expensive services needed by employees, and having your benefit administration consultants steer employees to providers that deliver the best quality at a reasonable price.
- Independent health plan pricing tools are dependent on fresh, accurate MRF data, so oversight of MRF quality is recommended
As a provider group, how can I benefit from transparency data?
- See whether your group has negotiated the most advantageous rates compared to other providers in the same network
- As we go through a period of rapid medical services inflation, find out what percent rate increases are negotiated by your competitors, before you sign your contract
- Boost your provider group by identifying providers who are stuck with substandard compensation from networks/carriers that you don't contract with
- Be empowered to shop around for network/carriers that offer superior compensation
What are the gotchas for working with these MRFs?
CMS did a lengthy comment period, resulting in numerous improvements to the original specifications. However, the lack of metadata (a table of contents) for the contents of each In-network Rates MRF serves as a barrier in making the transparency data accessible. As it stands it can be difficult to discern which MRFs must be processed to get relevant data. As a point of reference, UnitedHealthcare publishes approximately 22 thousand In-Network Rates MRF each month. And a minor detail is that the MRF files have an unusually complex NoSQL schema, and can be up to 1,000 Gigabytes (1 Terabyte) in size. Don't try to load these into Excel!
Should I build vs. buy? Is it feasible to build in-house technology to process these MRF?
Given that the CMS mandate for price transparency is a work-in-progress, any organization looking to build an in-house solution should expect substantial ongoing development cost. In addition, the technologies involved are 'big data' which is typically outside the comfort zone for the health IT industry. Until the government mandates are in final form, it's wiser to buy data or systems than to build in-house.
How often does the MRF data change?
- MRF files are updated monthly, with the latest rates and providers
- During the current high inflation period, expect dramatic rate changes upon the annual contract renewal
- During the year the contract year rates should stay the same, but expect a modest turnover in NPIs (and provider EIN) as providers come and go
Has the hospital price transparency mandate, which went into effect on January 1, 2022, had much effect?
The CMS mandate for hospitals to provide price transparency data for shoppable services has been a disappointment. Hospitals have dragged their feet in complying with regulations, and CMS is now forced to impose substantial fines for non-compliance. The #1 challenge is that the data posted is insufficient to answer the wholistic information needs by shoppers of medical services. The transparency data provides rates for specific services, but the consumer has little idea of how these services will be bundled. Consumers are also interested in the relative quality of the same service from different hospitals and providers, which is not presented. The # 2 challenge is that comparing hospital shopping lists is still a difficult apples-vs-oranges comparison between hospitals. CMS learned from the hospital experience, resulting in a more tightly defined schema for health insurance plan transparency. Here is an excellent article on the hospital price transparency situation
Will health plan price transparency have more impact than hospital price transparency?
The health plan price transparency should have more effect, but there are delays in accessing this data. The good news is that CMS has learned from the hospital transparency experience. CMS guidelines for health plan transparency make for an easier comparison between plans and providers. However, the health plan transparency MRF are large and complex, with some variances in structure from payer to payer.
What is the next milestone for health plan price transparency rule?
Starting on January 1, 2023 the rule requires health plans to offer an online shopping tool that will allow consumers to see the negotiated rate between their provider and their plan, as well as a personalized estimate of their out-of-pocket cost for 500 of the most shoppable items and services. Then starting on January 1, 2024, these shopping tools will be required to show the costs for the remaining procedures, drugs, durable medical equipment and any other item or service they may need. This quote is taken from CMS Newsroom